Outcomes of psychotherapy from the perspective of the users

A Scale for Measuring Positive and Negative Experiences of Psychotherapy (PNEP): First Psychometric Findings of a New Instrument for Monitoring Clients' Experiences

BACKGROUND

Clients' adverse experiences during psychotherapy are rarely monitored in clinical practice or research trials. One obstacle here is the lack of a measure to gauge both positive and negative experiences during psychotherapy. We developed and evaluated a new instrument for measuring such experiences.

METHOD

The Positive and Negative Experiences of Psychotherapy (PNEP) questionnaire was developed based on pilot data, a literature review, and two existing scales for measuring primarily adverse experiences during psychotherapy. Mental healthcare clients (N = 200) anonymously completed and evaluated the PNEP. Subsequently, a sample of professionals (N = 34) who underwent psychotherapy in the context of their training filled in the PNEP twice, with a 2-week interval in between.

RESULTS

The positive and negative experiences subscales of the PNEP were found to possess excellent internal consistencies (αs ≥ 0.90). The PNEP test-retest reliability was 0.93 for the positive experiences subscale and 0.78 for the negative experiences subscale. For the positive subscale, four factors were extracted: symptom reduction and positive well-being, high quality of therapy and therapeutic relation, personal growth and acceptance and interpersonal functioning. For the negative subscale, exploratory factor analysis suggested a three-factor solution: escalation of symptoms and emotional distress, low quality of therapy and therapeutic relation and (self-)stigmatization and dependency. Participants related a median of 13 positive and six negative therapy experiences to their most recent treatment. The most frequently endorsed negative experiences were having more negative thoughts and memories, feeling emotionally overwhelmed and an increase in stress due to the therapy. A minority of participants (10.5%) reported no negative treatment experiences.

CONCLUSIONS

In the field of psychotherapy, the evaluation of risks and benefits is crucial for assessing safety and effectiveness. The PNEP could be a promising instrument for achieving this objective, although further research is needed to replicate and expand upon the current findings.

What Works for Whom: Patients' Psychological Resources and Vulnerabilities as Common and Specific Predictors of Working Alliance in Different Psychotherapies

Background

Across different types of psychotherapy, one of the most robust predictors of better therapeutic outcomes is a good working alliance between patient and therapist. Yet there is little comparative research on whether particular patients more likely achieve a better alliance in certain treatments which represent particular therapeutic approaches or durations.

Methods

326 patients suffering from depressive and/or anxiety disorder were randomized into two short-term (solution-focused or psychodynamic) and one long-term (psychodynamic) therapy models. Treatments lasted ~7 and 36 months, respectively. Before randomization, patients were assessed with the interview-based Suitability for Psychotherapy Scale and filled Childhood Family Atmosphere and Life Orientation Test questionnaires. Patients filled Working Alliance Inventory after 3rd therapy session and at end of treatment; the long-term therapy patients, additionally, at 7 months' time point. Linear regression models were used.

Results

Greater psychological resources (e.g., capacity for self-reflection, affect regulation, flexible interaction) had little effect on alliance during the course of the short-term therapies. However, they did predict better working alliances at end of long-term as opposed to short-term therapy. Childhood adversities impacted alliances already at 7 months.

Conclusions

Although patients with certain qualities achieve better alliances in long-term as opposed to short-term therapies, apparently the theoretical orientation of therapy makes little difference. For patients with childhood adversities, differences between long-term (psychodynamic) treatment vs. various brief therapy models may be particularly salient.

A Pluralistic Perspective on Research in Psychotherapy: Harnessing Passion, Difference and Dialogue to Promote Justice and Relevance

The adoption of a pluralistic perspective on research design, processes of data collection and analysis and dissemination of findings, has the potential to enable psychotherapy research to make a more effective contribution to building a just society. A review of the key features of the concept of pluralism is followed by a historical analysis of the ways in which research in counselling, psychotherapy and related disciplines has moved in the direction of a pluralistic position around knowledge creation. Core principles of a pluralistic approach to research are identified and explored in the context of a critical case study of contemporary research into psychotherapy for depression, examples of pluralistically oriented research practices, and analysis of a pluralistic conceptualisation of the nature of evidence. Implications of a pluralistic perspective for research training and practice are discussed. Pluralistic inquiry that emphasises dialogue, collaboration, epistemic justice and the co-existence of multiple truths, creates opportunities for individuals, families and communities from a wide range of backgrounds to co-produce knowledge in ways that support their capacities for active citizenship and involvement in open democratic decision-making. To fulfil these possibilities, it is necessary for psychotherapy research to be oriented towards social goals that are sufficiently relevant to both researchers and co-participants to harness their passion and work together for a common good.

Conflicted Anger as a Central Dynamic in Depression in Adolescents-A Double Case Study

The incidence of depression in teenagers has increased for many years and is one of the most common diagnosis in adolescent psychiatry. Effective and accessible psychotherapy methods need sustained attention since psychopharmaceutic treatment might be less effective in younger people than in adults. The First Experimental Study of Transference-In Teenagers (FEST-IT) is a Randomized Controlled Study (RCT) with a dismantling design. The main intention in this study was to illustrate a way to address parts of a case formulation by focusing a psychodynamic feature in two different therapies with a good outcome suffering from depression. We present two representative patients from the FEST-IT with case formulations revealing conflicted anger. The patients were different in many aspects, as were the therapeutic methods. Therapies with and without transference interpretations may help to understand what is helpful in therapy in general. It may also show how a more individualized approach can guide the therapy beyond diagnosis and to make it more effective for the specific patient. Looking into individual cases with good outcomes can help us address dynamic features in therapy and give some ideas about what works for whom. The use of nested qualitative double case studies may together add more knowledge about working aspects in successful therapies.

Patient experiences of psychological therapy for depression: a qualitative metasynthesis

BACKGROUND

Globally, national guidelines for depression have prioritised evidence from randomised controlled trials and quantitative meta-analyses, omitting qualitative research concerning patient experience of treatments. A review of patient experience research can provide a comprehensive overview of this important form of evidence and thus enable the voices and subjectivities of those affected by depression to have an impact on the treatments and services they are offered. This review aims to seek a comprehensive understanding of patient experiences of psychological therapies for depression using a systematic and rigorous approach to review and synthesis of qualitative research.

METHOD

PsychINFO, PsychARTICLES, MEDLINE, and CINAHL were searched for published articles using a qualitative approach to examine experiences of psychological therapies for depression. All types of psychological therapy were included irrespective of model or modes of delivery (e.g. remote or in person; group or individual). Each article was assessed following guidance provided by the Critical Appraisal Skill Programme tool. Articles were entered in full into NVIVO and themes were extracted and synthesized following inductive thematic analysis.

RESULTS

Thirty-seven studies, representing 671 patients were included. Three main themes are described; the role of therapy features and setting; therapy processes and how they impact on outcomes; and therapy outcomes (benefits and limitations). Subthemes are described within these themes and include discussion of what works and what's unhelpful; issues integrating therapy with real life; patient preferences and individual difference; challenges of undertaking therapy; influence of the therapist; benefits of therapy; limits of therapy and what happens when therapy ends.

CONCLUSIONS

Findings point to the importance of common factors in psychotherapies; highlight the need to assess negative outcomes; and indicate the need for patients to be more involved in discussions and decisions about therapy, including tailoring therapy to individual needs and taking social and cultural contexts into account.

Understanding Long-term Outcome from the Patients' Perspective: A Mixed Methods Naturalistic Study on Inpatient Psychotherapy

OBJECTIVE

The complex phenomenon of psychotherapy outcome requires further conceptual and methodological developments that facilitate clinically meaningful research findings. In this study, we rely on an idiosyncratic and process-oriented understanding of treatment effects in order to investigate long-term outcome. A conceptual model of long-term outcome is presented that comprises both a taxonomy of change and explanatory factors.

METHOD

A mixed methods naturalistic study was conducted in an inpatient psychotherapy setting. Long-term quantitative outcome data are complemented with a data-driven thematic analysis of interviews with 22 participants, five to six years after ending inpatient psychotherapy.

RESULTS

Long-term outcome findings show improved well-being for the majority of former patients and this until five to six years after treatment. From the patients' perspectives, long-term changes can be situated on different interrelated existential levels: reconnection to others and (the meaning of) life, a revelation, an altered self, life changes, and altered expectations and ideas about recovery and treatment. The complex interplay of the person, the therapy centre, the outside world and the evolution over time helped explain the experienced changes and individual differences.

CONCLUSION

The findings support the value of an idiosyncratic and process-oriented understanding of outcome and recovery as well as substantiate the importance of multiple methods and perspectives when studying the effects of psychotherapy.

Childhood adversities as predictors of improvement in psychiatric symptoms and global functioning in solution-focused and short- and long-term psychodynamic psychotherapy during a 5-year follow-up

BACKGROUND

Childhood adversities are frequent among adults who seek treatment for depression or anxiety. These disorders are commonly treated by psychotherapy. Yet it is not known if specific types or durations of psychotherapy are particularly suited for patients who have suffered various early adversities.

METHODS

221 depressed and anxious adult outpatients from community, student, occupational, and private healthcare services filled the Childhood Family Atmosphere Questionnaire. They were randomly assigned to short- (solution-focused or psychodynamic) or long-term (psychodynamic) psychotherapy. Outcome was assessed via patient questionnaires and clinician interviews of psychiatric symptoms and global functioning during a 5-year follow-up. Linear regression analyses were conducted.

RESULTS

Less separations from caregivers expectedly predicted better outcomes in all therapies; unexpectedly, so did greater abuse. Family unhappiness and parental problems predicted faster or greater improvement when patients were assigned to a short- or long-term psychodynamic therapy model.

LIMITATIONS

As patients with psychotic, substance abuse, and severe personality disorders were screened out, findings might not generalize to these patient groups.

CONCLUSIONS

Patients with certain childhood adversities appear to respond with faster or greater improvement when the psychotherapy model is explicitly focused on working through the potential connections between past and current problems. If confirmed by in-depth studies, the findings may help match psychotherapeutic models with given patient complaints, as well as fine-tune different psychosocial interventions to individual needs for optimizing treatment outcomes.

How should we evaluate research on counselling and the treatment of depression? A case study on how the National Institute for Health and Care Excellence's draft 2018 guideline for depression considered what counts as best evidence

Background

Health guidelines are developed to improve patient care by ensuring the most recent and ‘best available evidence’ is used to guide treatment recommendations. The National Institute for Health and Care Excellence's (NICE's ) guideline development methodology acknowledges that evidence needed to answer one question (treatment efficacy) may be different from evidence needed to answer another (cost‐effectiveness, treatment acceptability to patients). This review uses counselling in the treatment of depression as a case study, and interrogates the constructs of ‘best’ evidence and ‘best’ guideline methodologies.

Method

The review comprises six sections: (i) implications of diverse definitions of counselling in research; (ii) research findings from meta‐analyses and randomised controlled trials (RCTs); (iii) limitations to trials‐based evidence; (iv) findings from large routine outcome datasets; (v) the inclusion of qualitative research that emphasises service‐user voices; and (vi) conclusions and recommendations.

Results

Research from meta‐analyses and RCTs contained in the draft 2018 NICE Guideline is limited but positive in relation to the effectiveness of counselling in the treatment for depression. The weight of evidence suggests little, if any, advantage to cognitive behaviour therapy (CBT) over counselling once risk of bias and researcher allegiance are taken into account. A growing body of evidence from large NHS data sets also evidences that, for depression, counselling is as effective as CBT and cost‐effective when delivered in NHS settings.

Conclusion

Specifications in NICE's updated guideline procedures allow for data other than RCTs and meta‐analyses to be included. Accordingly, there is a need to include large standardised collected data sets from routine practice as well as the voice of patients via high‐quality qualitative research.

The prediction of the level of personality organization on reduction of psychiatric symptoms and improvement of work ability in short- versus long-term psychotherapies during a 5-year follow-up

OBJECTIVES

How level of personality organization (LPO) predicts psychiatric symptoms and work ability in short- versus long-term psychotherapies is poorly known. We investigated the importance of the LPO on the benefits of short-term versus long-term psychotherapies.

DESIGN

A cohort study based on 326 outpatients with mood or anxiety disorder was allocated to long-term (LPP) and short-term (SPP) psychodynamic psychotherapy, and solution-focused therapy (SFT).

METHODS

The LPO was assessed by interview at baseline and categorized into neuroses and higher level borderline. Outcome was assessed at baseline and 4-9 times during a 5-year follow-up, using self-report and interview-based measures of symptoms and work ability.

RESULTS

For patients receiving SPP, improvement in work ability, symptom reduction, and the remission rate were more considerable in patients with neuroses than in higher level borderline patients, whereas LPP or SFT showed no notable differences in effectiveness in the two LPO groups. In patients with neuroses, improvement was more considerable in the short-term therapy groups during the first year of follow-up, and in higher level borderline patients LPP was more effective after 3 years of follow-up. The remission rate, defined as both symptom reduction and lack of auxiliary treatment, was higher in LPP than in SPP for both the LPO groups considered.

CONCLUSIONS

In neuroses, short-term psychotherapy was associated with a more rapid reduction of symptoms and increase in work ability, whereas LPP was more effective for longer follow-ups in both LPO groups. Further large-scale studies are needed.

PRACTITIONER POINTS

Level of personality organization is relevant for selection between short- and long-term psychotherapies. Short-term therapy gives faster benefits for neurotic patients but not for patients with higher level borderline personality organization. Sustained remission from symptoms is more probable after long-term than short-term therapy.

Experiences and perspectives of patients with post-polio syndrome and therapists with exercise and cognitive behavioural therapy

Background

Many persons affected with poliomyelitis develop post-polio syndrome (PPS) later in their life. Recently, the effectiveness of Exercise Therapy (ET) and Cognitive Behavioural Therapy (CBT) for PPS has been evaluated in a randomized controlled trial, but did not show a decrease in fatigue or improvement in secondary endpoints like Quality of Life and self-perceived activity limitations. The aim of this explorative study was to gain insight in the perceived effects and experiences of the interventions from the perspectives of the patients and therapists.

Methods

Qualitative data were collected through semi-structured interviews with 17 patients and 7 therapists. All participants were involved in the trial. A thematic analysis of the data was performed.

Results

Some patients experienced a short term enhanced endurance and a better use of energy during the day. However, in general patients did not experience a long lasting reduction of fatigue from the CBT or ET. Mainly patients of the CBT, but also some patients of the ET described an increase of self-esteem and self-acceptance. As a result, patients were sometimes better able to perform physical activities during the day. In contrast to the CBT, the ET was in general perceived by the patients as an intensive therapy, which was difficult to fit into their daily routine. Therapists of both the CBT and the ET struggled with a low intrinsic motivation of the patients in the study. This made it sometimes difficult for the therapists to follow the protocol.

Conclusion

Confirming the negative quantitative study outcome, the qualitative results did not demonstrate lasting effects on fatigue. Patients did, however, experience some benefits on self-esteem and acceptance of the disease. This study showed that it is of great importance to work with feasible interventions; they should fit the patients’ needs on a practical (fit into their daily routine) and mental (fit their need for support) level.

Measuring individual significant change on the Beck Depression Inventory-II through IRT-based statistics

Several researchers have emphasized that item response theory (IRT)-based methods should be preferred over classical approaches in measuring change for individual patients. In the present study we discuss and evaluate the use of IRT-based statistics to measure statistical significant individual change on the Beck Depression Inventory-II (BDI-II, Beck, Steer, & Brown, 1996). We compare results obtained with a simple IRT-based statistical test (Z-test) to those obtained with the Reliable Change Index (RCI) in a sample of clinical outpatients. Mean group differences between the Z-test and the RCI were similar, but for some individuals change classifications differed. Differences were most evident for change scores within the lower range of depression scores. We show that this may have consequences for the measurement of individual change in psychotherapy outcome research and clinical practice.

Use of auxiliary psychiatric treatment during a 5-year follow-up among patients receiving short- or long-term psychotherapy

BACKGROUND

The need for treatment is, despite of its obvious usefulness, a scarcely used measure of effectiveness in psychotherapy trials. This study considers changes in the need for auxiliary psychiatric treatment after starting short- and long-term psychotherapy and psychoanalysis.

METHODS

Altogether 326 psychiatric outpatients with mood or anxiety disorder were randomly assigned to solution-focused therapy (SFT), short-term psychodynamic psychotherapy (SPP), or long-term psychodynamic psychotherapy (LPP) while 41 self-selected patients were allocated to psychoanalysis (PA). The patients were followed for 5 years from start of treatment. Outcome measures were use of auxiliary psychotherapy, psychotropic medication, and hospitalization for mental reasons.

RESULTS

About 60% of the patients used auxiliary treatment during the follow-up. It was most common in the short-term therapy groups and its incidence was highest during the first year after the start of therapy. The average numbers of all therapy sessions among patients starting the therapy were 60, 70, 240, and 670 in SFT, SPP, LPP, and PA, respectively, whereas the corresponding average numbers of study therapy sessions alone were 10, 19, 232, and 646. Over 50% of the patients receiving short-term therapy received on average 4-6 times more therapy sessions than initially assigned.

LIMITATIONS

Post-randomization withdrawal was uneven.

CONCLUSIONS

Auxiliary treatment is usual among patients receiving short- and long-term therapies, and apparently becomes common shortly after the start of treatment. Auxiliary treatment can be used as an outcome measure indicating the need for treatment, should be monitored clinically and considered when interpreting the results of effectiveness studies.